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Daughter wins health insurance claim fight against LIC after 8 years, to get Rs 1.6 lakh as against Rs 17,100 paid by the insurer

The Life Insurance Corporation of India (LIC) was ordered by the National Consumer Disputes Redressal Commission (NCDRC) to pay Rs 1,60,812 after an 8-year-long battle with a ‘Jeevan Arogya’ insurance policy holder. LIC Jeevan Arogya is a health insurance policy that covers certain specified health risks and provides support in times of medical emergencies.

The primary reason for such an extended battle between the insurance behemoth and the policyholder was because LIC officials considered the surgery the policyholder was making a claim for was a non-major one and hence paid a smaller amount. They contended that despite the policyholder incurring Rs 2,16,827 for her father’s hernia operation, she was eligible for only Rs 17,100 insurance claim.

While LIC did not outrightly reject the Jeevan Arogya insurance claim, but the amount (Rs 17,100) offered to the policyholder for reimbursement of hospitalisation expenses of her father was too low since the policyholder already spent Rs 2,16,827 on various hospital bills. Disappointed with the lower claim amount, the policyholder decided to fight against LIC.

The complainant after completion of treatment of her father in Chennai returned to Agartala, Tripura and submitted her claim of Rs 2,16,827 along with medical prescriptions, bills and vouchers and other proofs with a forwarding letter addressed to the Chief Manager, LIC, Agartala Branch on August 8, 2016.

After receiving the documents and the forwarding letter, the manager (HI) of LIC’s Silchar divisional office asked the complainant for some information. The complainant replied to the queries on September 14, 2016. After receiving the replies, the Chief Manager of Agartala branch of LIC visited the house of the complainant on January 12, 2017.

On March 27, 2017 the complainant received a letter from the manager (HI) of LIC’s Silchar Divisional Office. The letter informed her (the complainant) that that claim raised by her was reduced to Rs 17,100 as of ‘Other Surgical Benefit’ under the policy. According to the complainant, she fulfilled the terms and conditions of the policy, but in spite of that, LIC had reduced her claim on the ground that ‘ventral hernia’ surgery was not a major surgery.

LIC reduced the surgery claim amount because laproscopic ‘ventral hernia’ surgery was not covered in the list of ‘Major Surgical Benefit (MSB)’. Further, LIC said that the insured ought to disclose the fact that her father was suffering from hypertension for ten years and coronary artery disease for the last six years which was within knowledge at the time of filling the proposal form.

Feb 02,2024

Source: Economic Times